Inspection on 02/11/05 for 35 Cranbrook Road

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 Cranbrook Road 14/06/07

35 Cranbrook Road 27/07/06

35 Cranbrook Road 19/05/05

35 Cranbrook Road 20/09/04

35 Cranbrook Road 21/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 35 Cranbrook Road Redland Bristol BS6 7BP Lead Inspector Nicky Grayburn Unannounced Inspection 09:30 2 November 2005 nd 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 35 Cranbrook Road Address Redland Bristol BS6 7BP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9442021 0117 9709301 Petercarter804@aol.com Aspects and Milestones Trust Mr Peter Carter Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 40 years and over. Date of last inspection 19th May 2005 Brief Description of the Service: 35, Cranbrook Road is operated by Aspects and Milestones and is registered to provide personal care and accommodation for up to five people with mental health needs who are 40 years and over. At present there are five men in residence, four of whom have lived at the home for a number of years. It is quite a large residential house, which blends in well with the local surroundings. It is built on three floors and would not be suitable for anyone with ongoing mobility difficulties. It is close to local facilities and amenities, including shops and public houses. It is also close to a main bus route. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, focusing on previously made requirements and recommendations, and compliance with legislation. Evidence for this report was gathered from examining residents’ individual files; records kept in the home; a self-tour of the property; and informal chats with the member of staff and residents. There was one member of staff on duty who has been working the home for nine years. The inspector met all five residents during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 ‘Terms and Conditions’ have been up dated, but need to detail all the conditions of living at the home in order for residents to be fully aware of their responsibilities. EVIDENCE: There have been no admissions into the home since the previous visit. Standards regarding the process were formerly inspected and scored ‘3’ for each. There is a comprehensive admissions procedure set out within the policy file. Four resident’s files were looked at and each had an up-to-date ‘terms and conditions’ for living at the home, which was a requirement from the previous inspection. This includes the complaints procedure and the required weekly contribution. However, there are also additional ‘conditions’ of living in the home, which should be included within the ‘terms and conditions’. There is a house brochure called ‘Bring a Resident’ which includes the conditions of the house. Within the policy folder there is a user-friendly licence agreement but it is not in use as the manager feels that the residents are able to understand the current format. The manager has since confirmed and sent copies of the signature pages from the contracts. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9 Reviews of individual care plans must be consistent to ensure residents’ needs are reflected within, and so staff can support them effectively. Residents are supported to take risks as part of their lifestyle. EVIDENCE: Residents have individual files containing a number of care plans. Most of the residents have varying levels of independence, which is documented in the files. Copies of the Care Plan Reviews with Bristol Social Services were present in the files. However, these were out-of-date and stated that the next review would be in March 2005. The member of staff confirmed that the reviews did happen at that time. The manager must ensure that the home receives a copy of the review to ensure that current needs and lifestyle is reflected in their individual plans, and for staff to be aware of any changes. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 9 The home’s personal care plans are in need of review. The majority were last reviewed in March 2005. These must be reviewed every six months, also as stated on each care plan. Previous reviewed care plans do not indicate that there were any changes. It is recommended that residents are involved with the review and is indicated on the plans. Staff write weekly comments for each resident unless something happens which is notable. It was apparent that the residents are a stable group. For the majority, the weekly records are being completed, but for one resident, there has been no input since 6/8/5. The home does not use formal handover forms as any issues are written in the communication book. The manager must monitor this method ensuring that communications between the team is fluid and recording is carried out on a regular basis. Risk assessments and strategies required from the previous inspection have been devised. Individual files must have a photograph of the resident. The manager has since stated that residents have declined being photographed. This must be recorded within the files. There is a pay phone at the end of the hallway for residents’ usage, away from the main shared spaces allowing a level of privacy. Residents’ meetings occur as and when needed, which allows the residents to discuss issues within the house. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15, 16, 17 Residents access the community and the house rules promote residents’ freedom. Family contact is well maintained by residents with the support from staff. Residents enjoy a healthy traditional diet. EVIDENCE: One resident has a voluntary job and is nearly ready for independent living and staff have been supporting him with this option. The decision remains to be his choice. Access to the Internet in the office has helped him to research possibilities of job prospects. Another resident attends art therapy and showed the inspector art work which he has achieved. Residents spoke of going into the community to use the local amenities, and it was observed that residents could come and go as they wish, as long as they told the member of staff. Residents said that they liked the area. Care plans are also in place to support residents in maintaining their interests and socialisation skills. The member of staff spoke of how some residents need more support than others to access facilities. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 11 The staff member was aware of each resident’s family relationships. Regular visits are made to relatives, some for over night stays. Relatives also visit the home. The majority of residents will be with family for the Christmas period. Within the individual files, care plans were in place to ensure that staff support residents to maintain this contact. Residents also spoke about recent visits to family members. Residents can have a key to their rooms. One resident confirmed this and said that he prefers his room to be locked to ensure others do not enter. It was observed that staff interact well with the residents and have a respectful relationship. Further, residents have unrestricted access to all shared spaces of the home. The weekly menu was on display in the kitchen indicating a nutritious and healthy diet. The meals are of a traditional British style, with lots of vegetables. There is also fruit available in both the lounge and dining room. The main fridge is kept locked due to a problem of excessive food going missing. There is now a policy for ‘Security of Communal Foodstuff’ detailing the reasons for this measure. There is another fridge for residents to access daily foodstuffs. One resident cooks for himself and has a key for the main fridge. The other residents eat together in the dining room, at an early time, but it remains their preference. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21, Health needs are met involving a team of professionals. Residents choose whether to attend health checks. Some residents are supported to selfadminister their own medication. The systems for administration for the other residents needs improvement as at present it could potentially place residents at risk. EVIDENCE: Residents have regular input from their relevant professionals. A Community Psychiatric Nurse (CPN) visited a resident during the inspection to administer treatment, and another had just returned from a Chiropodist appointment. Some residents confirmed that they do not want to attend dentistry or optician appointments despite saying that their eyes have worsened in recent years. Staff are to encourage residents to attend basic health appointments or seek other alternatives. Medication is kept in a locked metal cabinet in the office. The member of staff was confident about the medication system used in the home. The medication file was looked at. There have been a number of missing signatures on the Medication Administration Record (MAR) sheets in the past few weeks. It is required for all staff to ensure that they sign the MAR sheet if the medication has been given to ensure that residents are protected. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 13 There is an additional monitoring sheet for specific medications, which has to be checked at every shift change. Side effects from medication are listed on the cabinet. A reduction in dosage of medications is being monitored. Two residents self-medicate. Both residents, and the member of staff, confirmed that they have lockable units for the storage of their medication. Two residents had documents relating to their wishes at time of death. One resident has all arrangements in place, the other has refused to discuss or sign the document. Staff are to ascertain the wishes of death of the other three residents; state on the form that they did not want to discuss it; or liaise with family members in case they are not available at the time of the event of death. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Arrangements for protecting residents are not satisfactory placing them at possible harm and/or abuse. Whilst residents know how to complain, some choose not to. EVIDENCE: The complaints book was looked at and there have been no entries since August 2003. The member of staff said that the residents did know how to complain but they don’t. Whilst speaking with a resident, it was apparent that he had complained many times about an issue regarding another resident. It is required for staff to record all complaints and follow the stated Aspects and Milestones procedure of acknowledging it in ten days and completing the investigation within 28 days. The manager has since confirmed that there is another ‘complaints file’, with the last entry being 12th July 2005. All staff must be aware of where the complaints log is kept. This will be followed up at the next inspection. The notice board in the hallway displays details of who to complain to. This needs updating with the present CSCI details. There is an accessible, userfriendly complaints form in the policy folder. It is recommended that the manager distribute these for residents to keep in their rooms in case they do want to complain. One resident said that the manager has ‘always listened to me, to what I’ve got to say’. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 15 Another resident said that he does not complain because there have been breaches of confidences within the home, and gave an example of this. He was aware of the procedure and would go to Roger Green, Area Manager, if he had to make a complaint. It is recommended that staff are made aware of and comply with the confidentiality policy and respect residents’ privacy. Contact details for the CSCI were given to each resident with the leaflet ‘Is the care you get the care you need?’ A requirement from the previous inspection was for all staff to receive Protection of Vulnerable Adults training. This has not happened yet. It is vital for staff to be aware of the issues surrounding this as they are sole workers and deal with a vulnerable group of residents. The requirement remains and enforcement action will be taken if not accomplished. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 The standard of the environment in the home is good with planned improvements providing the residents with an attractive, clean and hygienic place to live. Residents are happy with their bedrooms and shared spaces. EVIDENCE: The two recommendations regarding the environment have been completed. The dining room has recently been decorated and is a light and pleasant room, and the external woodwork of the property has been repainted. Staff confirmed that the stairs and hallway carpet is due to be replaced on 08/12/05. There is a tidy garden ready for development next year. One bedroom was entered and was found to be large and very personalised reflecting the residents’ lifestyle. Two residents did not want the inspector to enter their rooms but confirmed that they had everything they wanted and needed in there. There are sufficient toileting and bathing facilities on each floor for the residents’ usage, all with hand washing materials. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 17 The main lounge is the smoking room, which has an air vent in one of the windows, as it has a smoky atmosphere. There is also a comfortable seating area in the open plan kitchen/dining area with another television and stereo. It is very important for some residents to have the option of spending time away from other residents, whilst not having to go to their rooms. The home was clean, tidy and hygienic. There is a weekly cleaning rota, which the residents have to be involved in. A resident explained that each resident is assigned to a particular chore for that week. One resident is reluctant to partake, but will with prompting and encouragement from staff. The notice board is looking a bit jaded with yellowed papers and old information. It is recommended that this be updated with a fresher look. One resident told the inspector “full marks to the manager to get things done, if anything needs doing, he gets it done”. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 Staff had a good understanding of their role; residents’ needs; and how the home runs ensuring a consistent service to the residents. EVIDENCE: Staff personnel files are kept locked and the manager is the sole key holder. Therefore, records were not seen on this occasion but will be the focus of the next inspection. Aspects and Milestones do have a robust recruitment policy in place. Residents spoke positively of staff members. A team of five staff members support residents. It operates with one member of staff on duty at a time, including a sleep-in shift. On the day of inspection, the member of staff who was on duty had worked at the home for over nine years; was confident; and knew the home and residents well. She was aware of her duties and responsibilities, and has had a number of years experience within the mental health field prior to 35 Cranbrook Road. A Community Psychiatric Nurse also supports some of the residents with particular issues. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 19 The member of staff has also completed NVQ level 3 in Independent Living and received Medication Monitored Dosage System Training last month. She confirmed that staff have been given the General Social Care Council’s Code of Conduct and that Aspects and Milestones ensure that each staff member have five paid study days a year to improve their competencies. A recent staff meeting addressed issues such as supervision. Evidence was seen of future supervision dates for certain staff members. It was confirmed that these are regular and staff feel supported by management. This standard will be fully assessed during the next inspection. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, 42 Systems for resident consultation are poor with little evidence that residents’ views are sought or acted upon. Policies and procedures are in place to protect residents. The home, and residents are safe and would benefit further from clear fire risk assessments. EVIDENCE: As required from the previous inspection, the home is to develop a formal quality assurance system to ensure that resident’s and their supporter’s views are listened and acted upon. It was unavailable on the day of inspection. The Manager has since submitted a copy of the home’s ‘Satisfaction Questionnaire Report’ completed by Rosanne Levene; ‘Service User Participation Worker’ for Aspects and Milestones from October 2005. Action from this will be followed up at the next inspection. Aspects and Milestones provide each home with a formalised set of policies and practices for both ‘Health and Safety’ and ‘Operational’. These have recently been updated and are due to be reviewed from June 2006. Blank forms are kept at the back of the folder for staff’s use. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 21 Individual resident records are kept in the office. One resident uses the office for Internet access, the office door is kept open, and residents come in and out of the room. It is required for these records to be kept in a secure location ensuring confidentiality and compliance with legislation. The fire logbook was examined and is well maintained. The relevant checks had been carried out within the required intervals and confirmed that all fire apparatus is in working order. However, no documentation for fire drills, fire safety training or generic and individual risk assessments for the property was available during the inspection. The member of staff could not locate any documentation either. These practices must be put in place and risk assessments be developed. The manager has since sent copies of the fire drills; last one being 17/03/05. The home’s insurance, including public, products and employers liability, document is within date. The Certificate of Registration is on display in the hallway. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 35 Cranbrook Road Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score X X 3 3 2 2 X DS0000026559.V262156.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard YA6 YA6 YA6 YA20 Regulation 15(1) 17(3) Sch 3(2) 13(2) Requirement Manager to ensure the resident and home receives the up-todate care plan after a review. Individual care plans are to be reviewed every six months and to involve the resident. Each resident’s file to contain a photo of the individual. Ensure staff sign MAR sheets to ensure administration and residents have taken their medication. Manager to obtain information regarding clients wishes at time of death. a) Residents have up to date details of the complaints procedure b) Staff to ensure that all complaints are logged and residents are confident that they will be listened to. Ensure all staff have PoVA training (Outstanding since 30/06/05) Personal individual files are to be kept in a secure unit. Staff to undergo fire safety training. DS0000026559.V262156.R01.S.doc Timescale for action 16/12/05 16/12/05 16/12/05 11/11/05 5. 6. YA21 YA22 12(3) 22 16/12/05 09/12/05 7. YA23 13(6) 16/12/05 8. 9. YA41 YA42 17(1)(b) 23(4)(d) 16/12/05 16/12/05 35 Cranbrook Road Version 5.0 Page 24 10. YA42 23 (4)(a) Risk assessment to be developed regarding fire. 09/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA22 YA24 YA40 YA42 Good Practice Recommendations Manager to distribute the user-friendly complaints procedure. Notice board to be updated. Staff to comply with the confidentiality policy. Fire drills to be documented. 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 35 Cranbrook Road DS0000026559.V262156.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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